Author Archive

Georgia Paxton, Gillian Singleton

Recommendations

Provide catch-up immunisation so people from refugee-like backgrounds are immunised equivalent to an Australian-born person of the same age.

Written records are considered reliable evidence of vaccination status.

In the absence of written immunisation documentation, full catch-up immunisation is recommended.

Routine serology against a range of vaccine preventable diseases (VPD) is not recommended to guide catch-up immunisation. Serology for hepatitis B infection and immunity is part of initial health screening. Offer testing for:

varicella serology (if ≥14 years if there is no history of natural infection)

rubella serology (in women of childbearing age).

Do not presume other providers are completing immunisation catch-up – be opportunistic – immunisation is the responsibility of all health providers.

+ Overview

People from refugee-like backgrounds are at significant risk of being unimmunised or under- immunised on arrival in Australia, due to their refugee and forced migration experience. Source country immunisation schedules225 are different to the Australian immunisation schedule,101 meaning no one will arrive fully vaccinated. Humanitarian crises are associated with disruption of health services and immunisation programmes, leading to issues with vaccine access and quality.226 Humanitarian entrants to Australia may receive polio vaccine prior to departure, and/or limited vaccines as part of the voluntary Departure Health Check (DHC);a,20 however, other humanitarian entrants may not be immunised and Expanded Programme of Immunisation (EPI) records are not required prior to travel. Asylum seekers will not be immunised prior to travel. Refugee and asylum seeker communities are also identified as being ‘at-risk’ of vaccine preventable diseases (VPD) after arrival,226 and there have been reported outbreaks of VPD related to refugee index cases.227–229

Although refugees may have received immunisations overseas, most do not have documentation of immunisation. There is often a clear verbal history of vaccinations, although there is debate on the validity of parental/self-recall of vaccination status.230–235 Written records are considered reliable evidence of vaccination status if available. In the absence of written immunisation documentation, full catch-up immunisation is recommended.236

There are limited recent Australian prevalence data on refugee immunisation – available studies show:

44–53% of asylum seekers still require catch-up immunisation on release from detention.237,238

50–98% of adult refugees from African and Asian source countries have incomplete immunisation according to the Australian schedule.

90–98% of child refugees (mixed cohorts) have incomplete immunisation according to the Australian schedule.39,108,231,239

Available data suggest the following prevalence of serological immunity (reviewed in239):

Limited data suggest that immunity to all components of combination vaccines (e.g. serological immunity to all three of measles-mumps-rubella) is much lower.43,46,231,240

Every attempt should be made to provide catch-up immunisation so people from refugee-like backgrounds are immunised equivalent to Australian-born people of the same age.

+ History and Examination

Assess any existing written immunisation records – overseas records (may require translation), detention health summaries for asylum seekers, other immunisation records, including the Australian Childhood Immunisation Register (ACIR) for children where vaccines were given aged <7 years. The expansion of ACIR to include all children and young people <20 years of age from 2016 will allow improved recording and review of previous immunisations.

Consider vaccines given as part of the DHC for offshore refugee arrivals – Mumps-Measles-Rubella (MMR) in people aged 9 months – 54 years, Yellow Fever (YF) and also Oral Polio Vaccine (OPV) depending on port of departure – these are all Live Viral Vaccines (LVV).19 Live attenuated vaccines (LAV), including LVV, should be given simultaneously, or at least 4 weeks apart. DHC immunisation may affect the timing of immunisation catch-up and also the interpretation of tuberculin skin tests (TST).

Assess for a clinical history of varicella infection.

Clarify hepatitis B status (for the individual and their household contacts) from initial post-arrival screening. This test may have been performed as part of pre-departure screening in unaccompanied or separated minors and pregnant women.

Consider the timing of the TST in relation to LAV administration – where TST is used for tuberculosis (TB) screening (i.e. in children). TST should be administered either before, or 4 weeks after LAV.236

Clarify whether immunisation has been commenced since arrival and if there is a catch-up plan in place. Asylum seekers who have been in held detention may have received some immunisations and they will have a written record.

Assess for any contraindications to immunisation or particular vaccines, completing the pre-vaccination screening checklist and relevant responses (tables 2.1.1. and 2.1.2 in the Australian Immunisation Handbook).236

Absolute contraindications include anaphylaxis following a previous dose/any component of the relevant vaccine.

LAV should not be administered to significantly immunocompromised people. MMR, varicella and zoster vaccines can be administered to people with Human Immunodeficiency Virus (HIV) infection who are mildly immunocompromised, after specialist advice.

Consider pregnancy in all females of childbearing age, including in adolescents. In general, LAV should not be administered during pregnancy, and women should be advised not to become pregnant within 28 days of receiving a LAV.236

Assess for the presence of a Bacillus Calmette Guerin (BCG) scar (deltoid, forearm, scapula, both sides and may be elsewhere). BCG vaccination leaves a scar in 92%–100% of recipients in prospective studies.241–243

a In 2016 extended screening will be implemented for the Syrian cohorts, with additional immunisations (MMR, polio vaccination and diphtheria-tetanus-pertussis vaccination – in the form of hexavalent or pentavalent vaccine in children <10 years – check available paperwork)

+ Investigations

Hepatitis B serology (see Hepatitis B) is part of initial post arrival health assessment. Hepatitis B serology is also recommended as part of routine antenatal screening for pregnant women in Australia. Adequate hepatitis B immunity is considered to be hepatitis B surface antibody (HBsAb) ≥10mIU/mL

Rubella serology in women of childbearing age – rubella antibody (Ab) is recommended prior to each conception, or early in the pregnancy – rubella Ab titres can fall post vaccination, and previous protective titres are not considered reliable evidence of immunity. Adequate rubella immunity is considered to be an Ab level above the accepted cut-off point for a given commercial assay (the WHO cut-off for adequate immunity is >10IU/mL). Women should be advised of their test result, as it is a clinically significant test.244

Varicella serology in people aged 14 years and older without a natural history of varicella infection.236,245,246

Routine serology against a range of VPD is not recommended to guide catch-up immunisation.236 Serology is not available for all vaccines, serological testing may not be reliable for vaccine-induced immunity, and immunity against a particular VPD may not change the vaccines required (with the use of combination vaccines). Serological testing prior to vaccination is cost effective for varicella245–247 hepatitis B248 and hepatitis A.249,250

Determine which vaccines have already been given – written records are considered reliable evidence of previous vaccination.

Aim for minimum number of visits, and minimum dosing schedules – therefore include vaccines where more doses are required (generally DTP, IPV, Hepatitis B, HPV) in the initial visit (see table 12.2). In general, catch-up immunisation can be provided over 3 visits, across 4 months in adolescents and adults (i.e. by giving the 3rd doses of DT containing and hepatitis B vaccine at the same visit), although recent changes to pertussis dosing and combination meningococcal vaccination may extend this to four visits for children <10 years. Where possible, immunise family members simultaneously to reduce the total number of immunisation visits.

Give combination vaccines where possible (to reduce the number of needles).

Consider formulations/licensing and age restrictions.

Consider recent or pending schedule changes.

Complete, but do not restart, immunisation schedules if there is written documentation of previous vaccine doses.

Provide opportunistic immunisation where possible, but do not interrupt other providers’ immunisation delivery if catch-up plans are in place.

Provide a written record and a clear plan for ongoing immunisation. It is useful to document which dose is being given e.g. MMR dose 1 of 2.

Vaccination information should be entered into the Australian Childhood Immunisation Register for children and young people <20 years (ACIR is transitioning to become the Australian Immunisation Register – AIR). From late 2016 it will be possible to enter data across the lifespan. This is intended to support changes to immunisation requirements for Centrelink payments, including those for childcare, after-school care, and Family Tax Benefit supplements. Children will need up-to-date immunisation records, or will need to have a catch-up plan in place, in order for families to access these payments, and refugee-like families may be particularly vulnerable to changes in Centrelink support.

For most vaccines, there are no adverse events associated with additional doses in already immune individuals. Frequent additional doses of DT-containing vaccines and pneumococcal polysaccharide (PS) vaccines (PS vaccines are not part of the catch-up schedule) may be associated with increased local reactions. If large local reactions occur with DT-containing vaccines, review prior to giving further doses, although the benefi of protection may outweigh the risk of an adverse reaction (e.g. protection against pertussis from a booster dose of diphtheria-tetanus-acellular pertussis).236

For families outside the initial stage of settlement – remind them to plan early for travel immunisations in the future. See www.cdc.gov/travel for information on destinations and vaccine requirements.

+ Considerations in Pregnancy and Breastfeeding

LAV (MMR, MMR-Varicella (MMR-V), Varicella Virus (VV), Zoster, YF, BCG, Rotavirus and oral Typhoid) are contraindicated during pregnancy and should not be given for 28 days prior to pregnancy.236

+ Considerations in Children

Consider the impact of age and how the child’s age relates to the Australian immunisation schedule delivery points (e.g. 9-year-old child who will turn 10 years before completing catch-up – thus changing vaccine formulations; consider which vaccines will be given in the future when the child reaches the schedule age).

Use positioning, distraction and measures to reduce vaccine-associated pain.236

Children aged <12 months are immunised in the anterolateral thigh or ventrogluteal area, after the age of 1 year vaccines can be given in the deltoid area of the upper arm.101 Usually only 2 injections per limb is practical.

Infants born to mothers with hepatitis B must have a birth dose of hepatitis B vaccine (preferably within 24 hours and definitely within 7 days) and also hepatitis B immunoglobulin (HBIG) – given in separate thighs – see Immunisation Handbook.

Key points

Identification of people from refugee backgrounds, including people seeking asylum, is important so that healthcare providers can tailor their approach.

There are a number of indicators that a person may be from a refugee background. These include:

country of birth

year of arrival in Australia

need for interpreter

preferred language

visa type

referral source.

Overview

If a person speaks a language other than English and comes from a country that has a history of conflict and human rights violations, e.g. Afghanistan, Iraq, Sri Lanka, Iran or Burma (Myanmar), they are likely to be from a refugee background. A country of asylum or transit such as Pakistan, Malaysia, Thailand or Egypt can also suggest a refugee background. Country of birth is not necessarily an indication of ethnicity or religious background.

People from refugee backgrounds can also be identified by their visa number, which indicates the category of Australia’s Humanitarian program under which they arrived. This includes entrants with the following visa subclasses:

Offshore – Refugee

Refugee Visa (Subclass 200)

In-country Special Humanitarian Visa (Subclass 201)

Emergency Rescue Visa (Subclass 203)

Woman at Risk Visa (Subclass 204)

Offshore – Special Humanitarian Program

Global Special Humanitarian Visa (Subclass 202)

Onshore Protection Program

(permanent) Protection Visa (Subclass 866)

Temporary Protection Visa (TPV) (Subclass 785)

Safe Haven Enterprise Visa (SHEV) (Subclass 790)

People seeking asylum

People seeking asylum who arrive in Australia and subsequently apply for protection as refugees have different visa types and eligibility for services.

Those arriving with valid entry documentation (e.g. a student or visitor visa) are permitted to reside in the community while their application is considered and are provided with a Bridging Visa after their original visa expires.

Bridging Visa A (Subclass 010)

Bridging Visa C (Subclass 030)

Bridging Visa E (Subclass 050 & 051)

People seeking asylum who hold a Bridging Visa E may have arrived without valid documentation prior to 2014. Those who arrived after this date were subject to transfer to Nauru and Manus. Also, some people who were transferred to Australia from regional processing centres for medical care will also hold a Bridging Visa E.

Visas are subject to change. For the most up-to-date information about visa types, see the Australian Government Department of Home Affairs:

Practice tip: Record country of birth, need for an interpreter, preferred language, date of arrival and visa number, in patient files to support care, particularly for people with special or complex needs.

People from refugee backgrounds may be referred by settlement and asylum seeker support services, refugee health nurses and services and/or specialised services for survivors of torture and trauma.

Considerations

People who have been in Australia for some time may not identify as refugees and may find questions about visa number details intrusive.

In some circumstances people from a refugee background may have a permanent or temporary visa (e.g. orphan, spouse, student, some people seeking asylum) that does not entitle them to Medicare, yet they may be unable to pay for healthcare services. These circumstances may require further advice and advocacy with local health and welfare agencies, and refugee and asylum seeker health services.

Jennifer Maclachlan, Benjamin Cowie, David Isaacs, Joshua S Davis

Recommendations

lived in a country with a high prevalence (>3%) of HCV (see table 5.1)

an uncertain history of travel or risk factors.

Initial testing is with anti-HCV test (HCV Ab). If this is positive, request an HCV RNA test.

If positive, refer to a doctor accredited to treat HCV for further assessment.

+ Overview

In Australia, more than 230,000 people (over 1% of the population) are estimated to be living with chronic HCV.111 The majority of these people have a history of injection drug use. However, other priority populations include people who have been incarcerated; recipients of blood, tissues or organs before universal mandatory screening of blood donors in relevant countries; people with tattoos, skin piercings or those who have undergone other cultural practices involving skin penetration or scarring; and people born in countries with a high HCV prevalence. The National Hepatitis C Testing Policy recommends offering testing to all people in these groups.

People from refugee-like backgrounds should be offered screening if they have a history of any of these risk factors, and/or have ever lived in countries with a high prevalence of HCV. 29 If a person’s travel or risk history is uncertain, they should be offered screening for HCV. In a number of refugee- source countries, such as Syria, accurate prevalence information is not available, and there have been reports of disruption to screening or surveillance for blood-borne viruses. A number of Australian seroprevalence studies have demonstrated a higher prevalence of HCV in refugees, including in those from the Mekong region (3-8%109), Burma (2.8%48), and Sub-Saharan Africa (4%107), although other studies have reported a similar prevalence to the Australian population (e.g. 1% in selected African migrants108).

Chronic HCV is usually asymptomatic; however, if undiagnosed and unmanaged, it can cause advanced liver disease and/or liver cancer. HCV treatment is in a stage of rapid development, with new, highly effective and well-tolerated curative treatments becoming available, emphasising the need for early detection and proactive management. These treatments do not include interferon injections, and have minimal side effects.

+ Investigations

The initial diagnostic test for HCV is an anti-HCV antibody test. Except in neonates, who acquire maternal antibody passively, a positive result indicates prior exposure to HCV. Approximately 80% of people who are anti-HCV positive will have chronic HCV infection. Chronic HCV infection is confirmed by HCV RNA PCR testing. All tests should be performed with the informed consent of the individual, or their legal guardian where relevant (e.g. parents providing consent for children).

Figure 5.1: Hepatitis C testing and management algorithm

Source: Decision Making in Hepatitis C (ASHM resource)

+ Management and Referral

If HCV serology AND HCV PCR are both positive, the patient has confirmed HCV infection.

All those who have confirmed HCV infection should have:

Counselling regarding the natural history, how to protect others from infection, the need for lifelong monitoring and the avoidance of hazardous alcohol consumption.

A targeted history and physical examination, looking for symptoms or signs of chronic liver disease.

Baseline LFTs, FBE, iron studies, UEC and upper abdominal ultrasound.

HCV genotype testing (this is Medicare-rebatable and can be requested by any doctor, not only specialists).

The following patients with chronic HCV infection should be offered surveillance for hepatocellular carcinoma, with 6 monthly ultrasound and serum AFP:

anyone with proven or suspected cirrhosis

anyone with a family history of HCC in a first or second-degree relative.

People living with hepatitis C should be vaccinated against hepatitis B if they are susceptible to HBV infection (HBV vaccine is funded for this indication in many jurisdictions), and they should be offered vaccination against hepatitis A virus (HAV) if they are susceptible to HAV.

From 2016, treatment for most people with HCV involves 12 weeks of all-oral combination therapy, with few adverse effects and a >90% chance of cure. Such therapy is available to those with access to Medicare, via the PBS from 1/3/2016.

+ Considerations in Pregnancy and Breastfeeding

The risk of HCV transmission from mother to child is approximately 3-5%. Neither the mode of delivery nor breastfeeding appears to affect this risk of HCV transmission. Note: HCV testing is not part of routine antenatal screening.

Current treatments for HCV infection are either known to be unsafe or have not been adequately tested to determine safety in pregnancy and while breastfeeding.

If a woman is diagnosed with HCV infection antenatally it is important to ensure the obstetric services are aware of her diagnosis. Seek specialist advice where concerned, and arrange ongoing follow up and management after delivery. Unnecessary instrumentation (such as fetal scalp electrodes and instrumental deliveries) should be avoided. Higher risk of mother-to-child transmission of HCV has been reported in the setting of maternal HIV co-infection.

+ Considerations for Children

Children born to mothers living with HCV infection should be tested at 12-18 months of age for anti-HCV antibody, to determine if they have acquired infection, with subsequent HCV RNA testing in children who are antibody positive to assess for chronic infection. Children with HCV infection should be referred to a paediatric viral hepatitis specialist for ongoing management.

Translated resources for patients

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The Australian Refugee Health Practice Guide was produced with funds from the Australian Government Department of Health.

Disclaimer

The information set out in the Australian Refugee Health Practice Guide (“the Guide”) is current at the date of first publication and is intended for use as a guide of a general nature only and may or may not be relevant to particular patients or circumstances. Nor is the Guide exhaustive of the subject matter. Persons implementing any recommendations contained in the Guide must exercise their own independent skill or judgement or seek appropriate professional advice relevant to their own particular circumstances when so doing. The statements or opinions that are expressed in the Guide reflect the views of the contributing authors and do not necessarily represent the views of the editors or Foundation House. Compliance with any recommendations cannot of itself guarantee discharge of the duty of care owed to patients and others coming into contact with the health professional and the premises from which the health professional operates.

Whilst the information is directed to health professionals possessing appropriate qualifications and skills in ascertaining and discharging their professional (including legal) duties, it is not to be regarded as clinical advice and, in particular, is no substitute for a full examination and consideration of medical history in reaching a diagnosis and treatment based on accepted clinical practices.

Accordingly, Foundation House and its employees and agents shall have no liability (including without limitation liability by reason of negligence) to any users of the information contained in the Guide for any loss or damage (consequential or otherwise), cost or expense incurred or arising by reason of any person using or relying on the information contained in the Guide and whether caused by reason of any error, negligent act, omission or misrepresentation in the information. Although every effort has been made to ensure that drug doses and other information are presented accurately in the Guide, the ultimate responsibility rests with the prescribing clinician. For detailed prescribing information or instructions on the use of any product described herein, please consult the prescribing information issued by the manufacturer.